Residents’ Section • Pattern of the Month

Krajewski et al.
Colonic Dilation

Residents’ Section
Pattern of the Month

Colonic Dilation
Katherine Krajewski1 Bettina 0361–803X/09/1935–W363

Siewert © American Roentgen Ray Society

Ronald L. Eisenberg
Colonic dilation (cecum > 9 cm or transverse colon > 6 cm) can be seen in adult patients
Krajewski K, Siewert B, Eisenberg RL presenting with a variety of medical and surgical conditions of the abdomen (Table 1). Acute
or progressive colonic distention may lead to colonic ischemia or perforation, and an accurate
diagnosis of the cause of distention is necessary to initiate appropriate therapy and prevent
complications. At times, it can be difficult to differentiate between low colonic obstruction
and pseudoobstruction, but certain imaging features and techniques can be helpful in making
the distinction. Important observations on radiographs are the distribution of colonic air, the
position of the dilated loops, and the presence or absence of air in the rectum.

Colonic Obstruction
Obstructing lesions produce intrinsic or extrinsic mass effect on the colon or rectum. The
colon is dilated to an abrupt transition point, and a lesser amount of colonic air, if any, is seen
distal to the point of obstruction (i.e., no air in the rectum). Compared with small-bowel
obstructions, colonic obstructions tend to be more subacute, with symptoms developing more
slowly. The major sites of obstruction in the large bowel are the cecal region, flexures, sigmoid
colon, and upper part of the rectum. Colonic obstructions occur more frequently on the left
side than on the right. They generally produce fewer fluid and electrolyte disturbances than
small-bowel obstructions.

Keywords: cecum, colon, colonic dilation, ischemia,

perforation

DOI:10.2214/AJR.09.3353

Received July 22, 2009; accepted after revision

September 1, 2009.

1All authors: Department of Radiology, Beth Israel

Deaconess Medical Center, Harvard Medical School, 330
Brookline Ave., Boston, MA 02215. Address
correspondence to R. L. Eisenberg
(rleisenb@bidmc.harvard.edu).

WEB
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 Krajewski et al.

Fig. 1—Cecal volvulus. Thin-walled cecum is markedly
distended. Because ileocecal valve is competent,
there is little small-bowel gas. (Reprinted with
permission from Eisenberg RL. Clinical imaging: an
atlas of differential diagnosis, 4th ed. Philadelphia,
PA: Lippincott Williams & Wilkins, 2003)
TABLE 1: Colonic Dilation
Fig. 2—Torsion of splenic flexure entering traumatic imaging: an atlas of differential diagnosis, 4th ed.
diaphragmatic hernia. Because of incompetent Philadelphia, PA: Lippincott Williams & Wilkins,
ileocecal valve, there is diffuse dilation of gas-filled 2003)
loops of both colon and small bowel, producing
radiographic pattern that suggests adynamic ileus.
(Reprinted with permission from Eisenberg RL.
Clinical

Obstruction
Neoplasm
Diverticulitis
Inflammatory bowel disease
Volvulus
Hernia
Intussusception
Impaction
Pseudoobstruction
Adynamic ileus
Ogilvie’s syndrome
Toxic megacolon

The radiographic appearance of colonic obstruction depends on the competency of the

ileocecal valve. If the ileocecal valve is competent, obstruction causes a large dilated colon,
with a markedly distended thin-walled cecum and little small-bowel gas (Fig. 1). If the
ileocecal valve is incompetent, however, there is distention of gas-filled loops of both the
colon and small bowel (Fig. 2), often with cecal hypertrophy and thickening of the haustra and
colon wall.
It is sometimes difficult to distinguish between a low colonic obstruction and colonic ileus.
In proximal colonic obstruction, the abnormal distention ends abruptly at the level of the
lesion; the colon distal to the lesion is free of gas. This transition is often impossible to detect
in low colonic obstructions. In such cases, radiographs should be obtained with the patient in
the lateral decubitus position (right side down). This position facilitates the entry of gas into
the rectosigmoid and rectum, unless there is a mechanical obstruction at or above this level.

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A B
Fig. 3—Ogilvie’s syndrome.
A, Supine abdominal radiograph shows gaseous distention of descending colon out of proportion to other
bowel loops.
B, Contrast-enhanced CT image shows dilation of entire colon and mild diffuse rectosigmoid wall thickening to
level of rectal tube, without obstructing lesion.

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A B

C D
Fig. 4—Adenocarcinoma of colon.
A and B, Supine (A) and upright (B) abdominal radiographs show moderate distention and stool in ascending
and transverse colon, along with air–fluid levels. Descending colon contains air but is not distended, and no
rectal air is seen. In setting of abdominal distention and constipation, large-bowel obstruction was suspected.
C, Single-contrast enema using water-soluble contrast agent delineates apple-core lesion of lower descending
colon (arrow). Small amount of contrast agent passes through tight and irregular narrowing of lumen. D,
Contrast-enhanced CT image in different patient shows dilated and stool-filled colon to level of obstructing
mass (arrow).

Distention of the rectum implies colonic ileus; a collapsed rectum suggests mechanical
obstruction. If there is doubt, a barium enema or cross-sectional imaging is required to show
the presence of an obstructing lesion or the patency of the colonic lumen (Figs. 3 and 4).
The major complication in colonic obstruction is perforation. If the ileocecal valve is
competent, the colon behaves like a closed loop, and the increased pressure caused by the
obstruction cannot be dissipated. When the colon is massively distended by gas, perforation
can occur. In acute colonic obstruction, the possibility of perforation is likely when the cecum
distends to more than 10 cm. In intermittent or chronic obstruction, however, the cecal wall
may become hypertrophied and the colon diameter may greatly exceed 10 cm without
perforation. Massive distention of the colon can compromise the mesenteric vascular supply,
leading to strangulation and bowel necrosis.
The most common cause of colonic obstruction is a primary colorectal neoplasm, which
often results in a characteristic apple-core narrowing of the colonic lumen on a contrast enema
examination (Fig. 4).

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A B

Supine abdominal radiograph shows dilated cecum

heterogeneous mass in pelvis, in expected location

of cervix, that encased sigmoid colon on contiguous
slices. Cecum is distended by dense stool, and
concern for pneumatosis or ischemia was raised.
Small-bowel loops are distended with fluid because

arrows
Clinical imaging: an atlas of

Metastases appear as filling defects of the colon or rectum, often with an intact mucosa
(Figs. 5A and 5B). At times, the colon wall can be involved with contiguous spread of a tumor
from an adjacent pelvic malignancy, such as ovarian or cervical carcinoma. Cross-sectional
imaging is helpful in making this diagnosis (Fig. 5C).
Diverticulitis is the second most common cause of large-bowel obstruction. Severe spasm,
an adjacent walled-off abscess, and fibrous scarring can produce marked narrowing of the
colon (Fig. 6). Similar segmental smooth or irregular narrowing can be produced by
inflammatory bowel diseases, such as chronic ulcerative colitis or Crohn’s disease.

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A B
Fig. 7—Sigmoid volvulus.
A, Supine abdominal radiograph shows massively dilated viscus with inverted U-configuration that extends to
level of hemidiaphragms. Apposition of medial walls of dilated sigmoid produces coffee bean sign. Rectal tube
was placed in this patient but did not provide symptomatic relief.
B, Diagnostic single-contrast enema was performed through rectal tube via gravity. Rectal tube traverses
persistent twist in sigmoid colon, with torsed mucosal folds outlined by contrast material. Volvulus forms
typical beak configuration through which contrast material cannot pass.

Oral and IV contrast-enhanced scout (

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Fig. 9—Fecal impaction. Abdominal radiograph shows

obstruction caused by impaction of large amount of
stool filling entire colon and rectum.

Volvulus of the large bowel is the third most common cause of colonic obstruction. Because
torsion of the bowel usually requires a long, movable mesentery, volvulus of the large bowel
most commonly affects the cecum and sigmoid colon; volvulus of the transverse colon occurs
infrequently. Colonic volvulus typically presents with a massively dilated viscus extending
into the upper abdominal quadrants. In sigmoid volvulus, a greatly inflated sigmoid loop
appears as an inverted U-shaped shadow that rises out of the pelvis in a vertical or oblique
direction, at times even reaching the level of the diaphragm (Fig. 7A). On contrast enema
examinations, the flow of contrast material ceases at the obstruction, and the rectum becomes
distended. The lumen tapers toward the site of stenosis, producing a pathognomonic beak sign
(Fig. 7B).
CT findings in sigmoid volvulus include disproportionate sigmoid enlargement, a
mesenteric swirl or whirl, and visualization of at least one sigmoid transition point. The
finding of two crossing sigmoid transition points at one location has been recently termed the
“X marks the spot” sign, whereas an incomplete sigmoid twist with intervening mesenteric fat
is called the “split-wall” sign.
In cecal volvulus, the dilated cecum is displaced upward and to the left and usually has a
kidney-bean shape, with the terminal ileum entering the cecum from the patient’s right side
(Fig. 8).
Cecal bascule is a variant of cecal volvulus in which the mobile cecum folds anterior or
anteromedial to the ascending colon, without a twist. Cecal obstruction occurs at the fold, and
competence of the ileocecal valve results in a large dilated cecum in the mid abdomen.
Colocolic intussusceptions result in telescoping colonic loops, often with a leading mass.
Colonic obstruction also may be caused by hernias, particularly in the left inguinal region, or
severe fecal impaction (Fig. 9).

Colonic Pseudoobstruction
Colonic dilation may occur in the absence of an obstructing lesion, as in cases of adynamic
ileus, Ogilvie’s syndrome, and toxic megacolon. In these conditions, colonic dilation may be
segmental or diffuse, and gas is generally present within the rectum.
Diffuse small- and large-bowel dilation without a point of transition is characteristic of
adynamic ileus. Among the numerous causes of this appearance are surgery, peritonitis, and
medication (Fig. 10).
Ogilvie’s syndrome is an acute or chronic pseudoobstruction that is often associated with
severe illness, recent surgery, electrolyte imbalance, and medications such as narcotics and
anticholinergics. It is thought to be related to altered autonomic control and is characterized
by disproportionate colonic distention with relative or intermediate points of transition, often
at or near the splenic flexure. However, there is no obstructing lesion or abrupt transition
between normal- and abnormal-appearing portions of the colon (Fig. 11). Despite the absence
of a mechanical obstruction, perforation can occur. Various modes of treatment include
supportive care, medication (parasympathomimetic agents), endoscopy, and surgery.

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A B
Fig. 10—Postoperative adynamic ileus.
A and B, Supine (A) and upright (B) radiographs show diffuse gaseous distention of colon with air–fluid levels.
Note presence of rectal air.

Oral contrast-enhanced coronal (

Descending and distal colon were normal in caliber,

Toxic megacolon is a complication of various inflammatory, ischemic, and infectious

diseases of the colon, but most often it is associated with ulcerative colitis. Although the colon
may be quite dilated in toxic megacolon, more specific features include marked bowel wall
thickening with loss of the haustral pattern in affected segments (Fig. 12). Nodular
pseudopolyps may

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A B

C D
Fig. 12—Toxic megacolon.
A–D, In patient with medically refractory ulcerative colitis, oral and IV contrast-enhanced scout (A), axial (B),
coronal (C), and sagittal (D) CT images show that ascending and transverse portions of colon are dilated and
contain both air and oral contrast material. Nodular pseudopolyps protrude into air-filled lumen (C).
Circumferential wall thickening extends from descending colon through rectum. Distention of ascending and
transverse colon continued to increase despite treatment, and patient ultimately required total colectomy.

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A B

C D

E F
Fig. 13—Invasive bladder cancer.
A and B, Supine (A) and upright (B) radiographs show distention of colon with fluid and multiple air–fluid
levels. One year after treatment with chemotherapy, cystoprostatectomy, and ileal conduit formation, patient
presented with 1 month of constipation. He underwent colonoscopy preparation without any passage of
stool. C, Water-soluble contrast enema reveals that smooth-walled rectum has very small caliber, much less
than that of sigmoid colon.
D and E, Sagittal (D) and axial (E) T2-weighted images with rectally administered negative contrast
administration show marked diffuse, circumferential thickening of walls of rectum and anus. F,
Contrast-enhanced T1-weighted image shows diffuse enhancement of thickened anorectal wall with
transmural extension of enhancement (arrow). Biopsy revealed poorly differentiated adenocarcinoma
with signet-cell-type infiltration, consistent with recurrent disease in anorectum.

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protrude into the bowel lumen with intervening gas-filled ulcerations. Crohn’s colitis,
ischemia, amebic colitis, and pseudomembranous colitis may also produce a toxic megacolon
pattern.
At times, it may be difficult to reliably differentiate between obstruction and
pseudoobstruction on radiographs. In these cases, a contrast enema may be helpful to exclude
an obstructing lesion if contrast material clearly passes the perceived transition point. This
technique may have the additional benefit of some therapeutic effect. It is critical to remember,
however, that in patients with suspected toxic megacolon, an enema of any kind (even using
water-soluble contrast material) is contraindicated because of the high risk of perforation.
Cross-sectional imaging (primarily CT and MRI) can provide additional information
regarding the site, degree, and cause of colonic obstruction (Fig. 13). These techniques show
the mechanism and site from multiple perspectives, particularly when multiplanar and
reformatted images are obtained. The obstructing lesion and its organ of origin may be better
delineated, particularly in cases of extrinsic disease. Cross-sectional imaging may permit
staging of malignancies and allow cases of pseudoobstruction to be diagnosed with improved
confidence.

Suggested Reading
1. Adler YT, Draths KG, Markey WS. Pseudoobstruction in the geriatric population. RadioGraphics 1986;
6:995–1005
2. Aufort S, Charra L, Lesnik A, et al. Multidetector CT of bowel obstruction: value of post processing. Eur
Radiol 2005; 15:2323–2329
3. Choi JS, Lim JS, Kim H, et al. Colonic pseudoobstruction: CT findings. AJR 2008; 190:1521–1526
4. Eisenberg RL. Gastrointestinal radiology: a pattern approach, 4th ed. Philadelphia, PA: Lippincott
Williams & Wilkins, 2006
5. Horton KM, Corl FM, Fishman EK. CT evaluation of the colon: inflammatory disease. RadioGraphics 2000;
20:399–418
6. Levsky JM, Den EI, DuBrow RA, et al. CT findings of sigmoid volvulus. AJR 2010 (in press)

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